Persistence, education are keys to growth of home dialysis program
Click Here to Manage Email Alerts
At our home dialysis clinic at Vanderbilt University Medical Center, working on growth and sustainability of our home program has brought along successes, promising endeavors and insight into potential challenges.
We have 117 patients in our program, 106 of whom are using peritoneal dialysis (PD) and 11 of whom are using home hemodialysis (HHD). We have seen a 124% increase in our PD and a 38% increase in our HHD census since April 2018.
Key to our successful home dialysis program at Vanderbilt is the education of patients and staff members. Early conversations about renal replacement therapy options with patients can help to alleviate anxieties and allow time for them to understand dialysis modalities and be prepared when it is needed.
Patient education
In addition to our discussions with patients, we have education visits and dedicated dialysis modality education visits at the home dialysis unit. At the home dialysis education visit, patients learn about both PD and HHD unless there is a contraindication to one modality. Nurses can assess potential challenges to home dialysis. For example, patients with visual impairment or severe arthritis can practice access connections to see if they will require assistance during dialysis.
For patients on in-center dialysis, the team evaluates potential candidates for home at the initial, 6-month and annual care plan meetings to determine which patients would benefit from additional discussion about home dialysis. Talking with the technicians and nurses can provide significant insight into the patient’s interest in self-care and ability to do dialysis at home.
Issues with adherence should be investigated as this need not be a barrier to home dialysis treatments. For example, patients who miss treatments due to transportation difficulties or patients who do not restrict fluids and sodium intake may thrive on home dialysis.
For patients who have not had ample time for dialysis planning, we have modality education, even for inpatient care, and can arrange home dialysis if appropriate. We have inpatient and outpatient urgent-start PD protocols. Patients starting HHD who do not yet have permanent access train with a tunneled dialysis catheter and then come back to complete training when the hemodialysis access is ready to use.
Transitional care
We are developing a transitional care unit to increase dialysis education and exposure to HHD. Patients who are new to in-center dialysis will spend 2 weeks on the conventional machine and 2 weeks on the NxStage SystemOne so they can experience both and receive additional education and emotional support at the start of dialysis. Prevalent in-center patients will also be able to experience dialysis on NxStage for 2 weeks.
We are hopeful this exposure will alleviate anxieties about home dialysis and make patients feel better and thus increase the use of HHD. As this program grows, we will work to incorporate new technologies and to increase self-care for those who stay in-center.
Liberal selection
We welcome a liberal selection approach at our program as there are few insurmountable medical barriers to doing dialysis at home. Patients with significant comorbid conditions or older patients may benefit greatly from home dialysis compared with in-center dialysis. To retain patients with a more liberal selection process, special attention should be given to changes in medical or psychosocial conditions and patients should undergo training again when appropriate. Our licensed clinical social worker works with patients and caregivers to address mental health issues, including burnout on home therapy, to reduce technique failure.
Nurses with in-center dialysis experience who then specialize in home dialysis can benefit from continuing education, such as conference attendance. We have a monthly case study meeting where we have presentations or pick a subject and review challenging cases so that nurses, dieticians, social workers and physicians can all learn from one another. It is important to collaborate with the in-center dialysis unit and kidney transplant teams who can be proponents for home dialysis as well.
Nursing shortage
One of the challenges of growing and expanding our home unit is the current nursing shortage. Due to a lack of teaching staff in nursing schools, approximately one-third of nurses at or near retirement age, and an ongoing pandemic, this challenge is likely to worsen in the coming years. Financial assistance for nursing schools may help with increasing the number of graduating nurses. Incentives may be needed to entice newly graduated nurses to plan early on to do in-center dialysis and then transition to home dialysis. Ensuring a reasonable nurse-to-patient ratio in the home dialysis unit is key to preventing burnout and retaining nurses.
In the setting of the COVID-19 pandemic, Vanderbilt University Medical Center has expanded the use of telehealth for patient care. Each quarter one of the monthly meetings is held face to face with the patient, but the other two of every three monthly meetings are telehealth.
This has allowed us to use telehealth for up to two of the three quarterly visits for stable patients on home dialysis. There is exciting potential for increasing the use of home dialysis with telehealth, which will be augmented as the infrastructure for internet access is improved.
New dialysis technologies may allow more patients to do dialysis at home by reducing training time or by having more portability. However, for some patients, dialysis that is more dependent on computer screens may be overwhelming. As more options become available for dialyzing at home, more individualization will be needed to continue growth and sustainability.
- References:
- Lew S, et al. Am Jrnl of Kid Dis.2020;doi:https://doi.org/10.1053/j.ajkd.2020.09.005.
- Osterlund K, et al. Sem in Dialysis.2014;doi:doi-org.proxy.library.vanderbilt.edu/10.1111/sdi.12183. For more information:
- Megha Salani, MD is director of the home dialysis program in the division of nephrology at Vanderbilt University Medical Center, Nashville, Tennessee. She can be reached at megha.salani@vumc.org.
Collapse
Read more about
Click Here to Manage Email Alerts